DDRS Waiver Manual

approved POC/CCB is automatically converted to a new annual POC/CCB. The total cost/amount of
services on the "auto-converted", or "default", POC/CCB is determined by the cost of services and
supports appearing on the most recently approved but expiring POC/CCB. The auto-converted, or
default POC/CCB ensures that there is no loss of services for the participant. The Case Manager is
subsequently contacted and required to complete the annual planning process, ISP, and POC/CCB
revision.
The plan is developed by the Individual Support Team (IST) identified by the participant. The participant
has the right and power to command the entire process. The Case Manager, participant and others of
the participant’s choosing form the IST. The POC/CCB is developed a minimum of six weeks prior to the
initial start date of services or six weeks prior to the end date of the current annual service plan. The
POC/CCB is routinely developed to cover a timeframe of 12 consecutive months.
The POC/CCB is driven by a person-centered planning process, coordinated in conjunction with the
participant, his or her guardian or legal representative, and members of the individual’s support team.
Case Managers are responsible for the facilitation and development of the participant’s Person-
Centered Plan (PCP), which must include the following five key components:
1. Personal priorities, which includes the personal priority statements and personal
priority narratives;
2. Relationships;
3. Communication;
4. Outcomes; and
5. Historical narrative.
The PCP is to be updated at least annually and is to ascertain the participant’s needs, wants, and desires
using person-centered planning philosophy processes. A participant’s PCP should be reflective of his or
her strengths, preferences related to relationships, community participation, employment, income and
savings, healthcare and wellness, and education, as well as long-term hopes and desires, so as to develop
an Individualized Support Plan (ISP) that encourages and supports the achievement of these goals.
Utilized at initial intake and at least annually thereafter, the PCP process accounts for and documents the
participant’s preferences, desires, and needs, including his or her likes and dislikes, means of learning,
decision-making processes, management of finances, and desire to be productive and employed. It is the
Case Manager’s responsibility to ensure the person-centered planning (PCP) process is conducted using
plain language and that the process is timely, occurring at times and locations of convenience to the
participant. Each participant’s ISP will then be reviewed and/or updated at least every 90 calendar days as
part of the participant’s 90 Day Meeting with the IST.
A state-approved risk assessment tool is completed by the case manager to help identify risks related to
health**, behavior, safety and support needs for waiver participants.
** For the CIH Waiver, note that, when participants have State-assessed health scores of 5 or
higher and opt to utilize the waiver’s Wellness Coordination services, healthcare needs and
associated risks are separately assessed and monitored by a registered nurse (RN) or licensed
practical nurse (LPN) employed by their chosen Wellness Coordination provider agency. The
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